India Insight: Medicine, Profit and Dharma

This week Encounter checks out the state of medical ethics in India and the resources Hinduism has to offer for thinking through some of India’s contemporary medical ethics issues. From the Indian Journal of Medical Ethics to a remote rural hospital run by followers of Swami Vivekananda, a picture emerges of many challenges, some of which have an Australian connection.

Transcript

Margaret Coffey: On my first visit to India I got to know roads – one minute a modern multi-lane tolled freeway, the next a road the monsoon has been sweeping away, layer by layer, year by year, because the powers-that-be haven't, so far, got around to fixing things up between seasons. Driving on this one means zigzagging between giant potholes and even fissures, all the while avoiding cars, trucks, carts, people, animals…….The little Tata was carrying us to the very small town of Sargur, south west of Mysore, itself in the south west of India. Actually there's a bit to go beyond Sargur, on an even poorer road - where I'm heading is classified as a 'remote area', but really - in Australian terms – it's the quality of the road that makes it remote, not the proximity of jungle forests or the distance from big cities.

I'm heading for a hospital run by the Swami Vivekananda Youth Movement, named after the 19th century Hindu monk and disciple of another great 19th century figure Ramakrishna. Vivekananda - born 150 years ago this year - became famous in the West when he turned up at Chicago's Parliament of Religions in 1893, but he was first - and remains - an inspiring figure in India. He wanted to revive Hinduism so as to revive an Indian nation, in order to develop India's people - not contemporary RSS style or BJP style Indian nationalism. I'm here to find out what Vivekananda's ideals look like when put into practice today, because as you'll hear in this program, India needs those promptings.

My host is pathologist and bioethicist Dr Sridevi Seetharam – she joined the Swami Vivekananda Youth Movement or SVYM when she was a medical student.

Dr Sridevi Seetharam: I joined the organisation in my second year of medical school. At that point in time we did not have any activity in the rural area. It was just a group of like-minded people who would conduct weekly camps for the under-privileged or under-served areas, visit a few old aged homes, or conduct first-aid camps, like something out of the ordinary with a sense of social service. And after my medical school when I realised that I have an opportunity to come back here full-time it was much more meaningful to consider a career here rather than going into a regular career which offers little more than just being a lucrative profession. The way the medical practice is practised in India today – health can be sold or bought or lended. So I don't think it is a commercial commodity, it is definitely a social good and should be nurtured in a very different way.

Margaret Coffey: In India health care and medical services are social goods poor people and rural people have limited access to. There's an enormous shortage of doctors in rural areas, in tandem with huge health needs. The growth in the health sector is happening where it brings profit – in the burgeoning number of private hospitals designed for high paying customers, who are drawn from India's expanding middle classes and from other countries. These customers are attracted by the specialised services hospitals may offer, with the government's policy settings encouraging the growth of medical tourism. In the publicity spin, India is a low-cost, high tech, high quality healthcare destination, and Australians are among those who buy the publicity.

I've set out from Bangalore, where yet another kidney transplant scandal was exposed some weeks back – it involved private hospitals in Bangalore, poor villagers who'd sold their kidneys, and properly constituted ethics committees, filled with professionals including lawyers, that had authorised the improbable so-called 'donations' without proper scrutiny. There are mandated structures and processes in place to manage organ donation, but evidence shows that commercialisation of human kidneys is as common now as it was before those reforms were introduced. India inherited its so-called allopathic or Western medical training systems from the colonial period. But the current failures in the system are of India's making – that's what I was told by the current editor of the Mumbai based Indian Journal of Medical Ethics, Dr Amar Jesani. As luck had it he was out of the country when I was there, so we caught up by phone.

Amar Jesani: The kind of medicine that is practised in India I can't blame it on the Western forces. It has to be blamed on the kind of system that we have built here. Perhaps you can say that it had colonial roots – some of our culture was shaped by them. But that does not mean that we did not have space to reform it after independence and here we have failed and we have allowed a system which is completely market based without having strong regulation, without having you know medical professionals commitment for making health care accessible to all. As a consequence it is a system which is very based on inequity and on injustice and that has been having a lot of repercussions on the way medicine is practised in India.

Margaret Coffey: There's another point he makes about religion as a potential check on corruption and about the potential for individual doctors to choose the wrong side.

Amar Jesani: You know if you have seen what is happening in the political sphere in India you will realise that the revivalism of religion in India in the last three decades has played a very destructive and violent role. The second thing is that you will also see that there is a participation of members of the medical profession in this violence. So you will find that some of the terrorist violence by the minority communities there are some doctors involved in it. On the other hand you will find that there has been considerable involvement of doctors, even separate association of doctors, in the violence carried out by the majority. Recently there was a judgement in violence in Gujarat case in 2002 where the mobs were led by a gynaecologist who was the leader of that community. So you will find the medical profession getting affected by the division of the country on the basis of the violence. And as a consequence it has a certain impact on the way medicine is practised. People do think about the communities and all, that is one. Yes, we want to look at Indian philosophy and religious philosophy but at the same time we want doctors to have engagement with those philosophies in order to strengthen their healing role, to strengthen their humanitarian role, and not to get carried away by those leaders who are trying to use religion in politics for their own purposes. It is a very, very, very big challenge. So when we do reflection on religion we have to be very balanced and cautious in a multi-cultural, multi-religion setting like India.

Margaret Coffey: We'll hear more from Amar Jesani but I want to see a place that tells a creative story – and SVYM's hospital at Saragur does just that. It serves a population of indigenous tribal peoples, rural people and re-settled people, including Tibetan refugees. For all these people money and opportunity is very, very short. And like the majority of Indians they certainly don't have access to the services bought by Australian, British and North American medical tourists.

Sound of SVYM Hospital

Dr Sridevi Seetharam: So this hospital was started about eleven years ago and before that we had another hospital about 15 kms away and Swami Vivekananda is the inspiration for the organisation – his values for nation building, man making and service.

Though he's known as a Hindu monk, the ideas that he stood for and the values that he propagated are kind of universal and even his view about religions said that - each religion is different path, that's all. So whatever he's preached would be relevant to a person from any religion. It's nothing specific to a Hindu or what a Hindu stands for. And that appeals to all of us and the organisation is also secular in that sense. We are non-religious in a sense. It’s not that we don't believe in God – we don't have a religious agenda.

Margaret Coffey: The hospital is one element of SVYM alongside schools, development activities, and some really inspired ways of reaching people in their villages in a manner that improve lives in the long term.

Dr Sridevi Seetharam: The disease spectrum is largely infectious. We have the usual respiratory infections, gastro-intestinal diseases. We have quite a bit of tuberculosis in India, HIV, epidemic I think after South Africa in absolute numbers we are the number two in the world.

Dr Sridevi Seetharam: It is there everywhere. In this hospital we give integrated care – there is no difference between positive and zero cases. Patients appreciate that.

Margaret Coffey: What about TB?

Dr Sridevi Seetharam: It is similar to the national figures, about 2 per cent. Most of them are pulmonary tuberculosis so it is a concern not only for the patient but also for the family. It spreads by coughing and droplets. So you must have seen the crowds everywhere – crowded buses, crowded theatres, crowded marketplaces. So it is very easy for the transmission to occur.

Margaret Coffey: Nobody is unaccompanied here in outpatients – and all the diversity of the hospital's geographic location is represented – including many tribal people and a Tibetan woman in traditional dress.

Dr Sridevi Seetharam: It's really hard. If they come to the hospital, usually a family member has to accompany them. So if both are earning members in the family that means loss of wages of two people. Here in the hospital we try to keep the turnover time reasonably high – then they can finish all their tests, their consultations, get their medications, everything, in one day. So they are all small micro-health economics which don't really factor in to a medical education.

Margaret Coffey: The hospital runs a mobile health van that routinely reaches into the villages, even deep into the forests...

Dr Sridevi Seetharam: They live in such remote areas that to get a bus, to get bus fare, to get the space and time to actually visit a hospital – all this is a huge burden for care. So the mobile health van addresses a lot of those issues – it goes right to the doorstep of the village. In addition we also support the government health workers in reaching these tribal hamlets so that they can do the child immunisation and provide ante-natal care to the pregnant women.

Margaret Coffey: So this ambulance goes with a doctor and a nurse?

Dr Sridevi Seetharam: Yes, a doctor and a nurse and/or a health worker, what we call a health facilitator, and the driver. And the health workers are largely drawn from our local community, so they are the local people. So we are actually the outsiders here – but they are a huge help for us because they know the local dynamics, they know how to say things and how to get some response.

Margaret Coffey: The villages are out there – it's jungle out there, isn't it?

Dr Sridevi Seetharam: Oh yes. Some of the tribal hamlets are located a kilometre or two from the main road, just a dirt track. In the rainy season it is very difficult for our vehicle to actually reach there. So you can imagine how difficult it would be for these people to access the main road by walk, wading through slush and dense vegetation.

Margaret Coffey: It's a wonderful achievement, this now 90 bed multi-specialty hospital. I wanted to see it because it tells a story that's not in the headlines, so it's not about corruption in medicine, in government, in business. It's about ideals drawn from the wellspring of Indian tradition. Sridevi's husband, Seetharam, an orthopaedic surgeon, is today president of the Swami Vivekananda Youth Movement. The movement earned its name almost 30 years ago, in the early 80s, when its founders were truly youths.

Dr Seetharam: It so happened that there was a bunch of us who thought differently, who dared to dream differently and probably also dared to live out that dream.

During those days we would hear from all people around that things were not really going on well in medical profession, not really flattering to the medical profession. But then we came with the idea that medicine is a very noble profession and whatnot. We were strongly influenced also during those periods of time by thoughts and writings of Swami Vivekananda and Mahatma Gandhi. Mahatma Gandhi said 'be the change you want to see', so during those days we started very small, like you know helping patients who were admitted in the teaching hospital, doing some blood donations and such stuff. Then we were running a weekly free clinic in a village nearby.

Margaret Coffey: Then in the late 80s these students were introduced to the area where they've now built a hospital. I'm told the landscape around is usually green at this time of year, but when I see it, on the cusp of monsoon, years of drought are telling. In the nearby riverbed there's little water for the women washing clothes.

Dr Seetharam: This was a place where a lot of resettlement had happened with very little rehabilitation. Because of many developmental projects people had been displaced. Indigenous tribals as well as the non-tribal communities had been relocated in new villages but in terms of basic developmental initiatives support like education, health, infrastructure, even basic infrastructure like roads, power etc nothing much had been done. So it was a challenge when the district administrator said you have been taking a lot, so this is a place which needs you, can you really do it. I guess at that point in time all we had was these ideals and a lot of youthful impulsiveness and absolutely no money and no resources but we felt this is resources enough. And so we jumped into it.

I guess from that point onwards it has been an evolution – continuous learning process.

Margaret Coffey: It is so sophisticated now – the integrated thinking about development, education, outreach – all of that.

Dr Seetharam: You said it right. When we came here we very frankly confess that we had very little idea of what development might be. We were trained as doctors; actually we were trained as clinicians: we knew how to put a steth on this chest and identify some diseases, maybe interpret some blood report and label a patient as a diabetic or whatever. We also had the knowledge of a few prescriptions. Given our enthusiasm in those days we thought that could change the world. The community has been the best teacher we have had. So when we were trying to treat diseases – let's say scabies or some skin infection. We knew what medicines to give and we gave them – we realised that it didn't cure the people; they would come back a week or two weeks later with more florid infection - we would repeat the treatment and they would repeat the visit and so you know it would go on. Then we started realising that there is more to health than medicines. So we ventured into determinants of health like water, sanitation, housing, environment and other things. We also realised that expectations of patients are also to be taken into consideration. Like if I started telling them about preventive medicines, let's say a patient with a cold, upper respiratory infection, came and I just told them about the safe water practice, or gargling with saline water or whatever it is, that wouldn't satisfy them. It had to be combined with a prescription of a pill. So the importance of institutional care along with community based education struck us and we developed a model around that. We also realised that the uptake of our advice was not as much as we would have like it to be and that had actually been influenced by a lot of other factors which are not really health related – they were a lot of cultural issues, social issues, educational issues, ethnic issues. So unless we look at it as a package we can't really make a dent and the little change that we would make would be very short-lived - it wouldn't be sustainable at all. And so we opened our eyes to all these aspects which are so closely intertwined and inter-linked that you cannot work in compartments. You cannot say that I am a doctor and do only doctoring. You have to be looking at the educational status and trying to impact that, you have to be looking at economic status as well and trying to impact that. The interplay between poverty and health has been something that we have really seen and experienced here so unless we address that health can never be achieved.

Margaret Coffey: And so SVYM has flourished, delivering on all those fronts. It runs schools, training, social empowerment projects, alongside health care in hospitals and in the community. And it returns constantly to the founding principles acquired from Swami Vivekananda and Mahatma Gandhi.

Dr Seetharam: Yes, we do. We make it very clear to our staff members and the community outside that we are in no way religious but in as many ways as possible we are spiritual. And service for us is one of the important components there. We believe in four values as the important ones that we want to adhere to. Satya and Ahimsa, that is truth and non-violence which Mahatma Gandhi highlighted and practised, and Seva and Tyaga - that is service and renunciation, which Swami Vivekananda said would be the actual basis for [the] evolution of any human being. Yes we have formal as well as informal ways in which we try to promote these values within the organisation and also introduce these to the community outside. We have regular meetings in which the works of Swami Vivekananda and Mahatma Gandhi are discussed and presented by staff members themselves. And in each of the projects that we undertake we try to include components of these so that they are reiterated as many times as possible. We believe in transparency. All money that we receive is an open book. So all staff know how much money comes in and what it is spent for. So these are actually ways in which the values are reinforced much more strongly than in a sermon.

Margaret Coffey: It does work! We'll return to Saragur later in the program to hear how.

I'm Margaret Coffey - next a private hospital in Mumbai, but this one dates from the sixties, prior to the rush of new hospitals, and it was the endowment to the city of a devout Hindu donor. I'm saying that because I have in my ears the words of the editor of the Indian Journal of Medical Ethics, Amar Jesani:

Amar Jesani: We have published a lot on medical tourism in India, both general medical tourism as well as medical tourism related to the assisted reproduction, you know something which are becoming very big and distorting the medical system completely. The second area is out-migration of doctors, doctors leaving India, not only to Australia but to the other countries - US is the biggest importer of Indian doctors, and so is the UK and now Australia and to us this is nothing but a kind of poaching of medical human power. It's globalisation of market, it is globalisation of skill, but it is not globalisation of labour where everyone cannot go everywhere else to find jobs. So, in this kind of situation there are unequal relationships and that has tremendous ethical implications for the health services in India. It is also fuelling the market for setting up more private medical schools where then can charge exorbitant fees to train doctors who are going to go out of India to serve others. Yes Indian businessmen are making big money in the medical education and setting up big hospitals. But the Indian people, the common people who are deprived of the health care they are not gaining anything out of it and so the whole globalisation and global health policies are based on very iniquitous, unethical principles. So that is what we have to critique in coming time.

Margaret Coffey: You're with Encounter on RN – and you can find a transcript and other information about the program at RN's website – just locate Encounter.

Sound inside Jaslok Hospital

Margaret Coffey: I'm at the Jaslok Hospital, just a stone's throw from Mumbai's Arabian Sea shore, making my way through the crowded entry to meet Dr Sunil Pandya.

Dr Sunil Pandya: It's one of the older private hospitals of Bombay. It was set up by a family trust – the community to which the donor belonged is the Sindhi community. He got a retired professor from the Grant Medical College which is my alma mater, his name was Dr Shantilal Mehta - he got that gentleman to establish this hospital. It's a multi-specialist hospital – extremely well equipped and it attracts patients from a fairly wide geographical area including patients from abroad, from the Gulf countries, from Malaysia, from Bangladesh of course, Pakistan, Nepal, Ceylon.

Dr Sunil Pandya: Yes as you enter the hospital itself on the right hand side there's this prayer room but the images there are those of Hindu gods. But of course anyone is welcome to enter and pray. I'm afraid the limitations of space perhaps don't allow dedicated temples or churches or mosques or whatever within the hospital premises, so I think they have rested content with the faith of the founder of the hospital.

Margaret Coffey: Dr Sunil Pandya is a neurologist [neurosurgeon], and the recently retired editor, now Editor Emeritus, of the Indian Journal of Medical Ethics. He was part of a group that back in the 1990s set up what was first a simple photocopied newsletter. As he tells the story, it was Mahatma Gandhi's injunction to 'be the change you want to see' that got the group going in response to what was even then rampant corruption.

Dr Sunil Pandya: About 20 years ago the elections for this Maharashtra Medical Council were imminent so somebody told us – why don't you stand for election? We had never even considered remotely standing for elections. First of all elections are very expensive and the group that I am talking about were all people who had very, very minimal incomes – in a teaching hospital you don't earn much. But we were quite taken up with this criticism, that you keep on grumbling but not doing anything so we stood for election, about eight of us. It cost us quite a bit of money but we stood for it and of course we were roundly defeated, every one of us. But what happened was we were able to document that the elections were rigged because we were able to record individuals coming with 5000 votes, 10,000 votes and depositing them in the electoral office – which is a patently unethical and also illegal activity. So after the election results were announced in which we were defeated, we filed a case in court and we had amongst us a doctor, Manohar Kamath, who has a legal background - he fought this case on behalf of our little group. In India any legal case takes years and years and years because the systems are very, very poor and they allow adjournments at the drop of a hat and so in India we have a backlog of God knows how many millions of cases for decades, so our case also took its own sweet time but when it came to judgement the judge ruled in our favour, said that the election was rigged and disqualified all the members and dissolved the council. We thought we would be very happy at this but we weren't because what happened was that the government appointed its own nominees on the Medical Council and ran the Medical Council as a government enterprise for years. So we were from the frying pan into the fire, because governments in India are not reputed for their scrupulousness, or integrity or efficiency. We decided that we had to do something as an ongoing measure.

Margaret Coffey: What they did included the newsletter precursor of what is now the impressive Indian Journal of Medical Ethics. You can go to its freely accessible website to check it out. Just search for the title – or find the link in this program's transcript – available at RN's website. http://www.ijme.in/

Dr Sunil Pandya: What is nice is that this journal has survived and now is an indexed journal and from 16 pages it is now to over a hundred pages and now we have contributors from abroad. We have our own website, where the journal is on, full text, completely free, and you download any article that you want, starting from the very first 16 page thing up to the very latest journal.

Margaret Coffey: And there's an Australian connection in a member of the Journal's editorial board – Professor Bebe Loff from Monash University .

Sunil Pandya has a practical explanation for the ethical issues that confront Indian medicine.

Dr Sunil Pandya: The general commercialisation which has set in and the general worsening of ethos everywhere - in the judiciary, in the police, in the government has unfortunately also seeped into the medical profession and it became worse when the government sanctioned the creation of private medical colleges. Now these private medical colleges charge a huge sum, huge sum, so by the time the boy graduates or the girl graduates from medical college they have already spent, in Indian terms, lakhs of rupees. So the first thing he has to do on graduation or she has to do, is to recoup that amount and then make a profit on that investment. You can't do that ethically, there's no way. There's no way you can earn lakhs and lakhs of rupees when you start practise – it takes years to build practise and these people need money instantly, as soon as they have graduated. So if I am a surgeon and you are a general practitioner I'll come to you and say look why don't you send me patients for surgery and I'll give you 30 per cent of my charges to the patient, in some cases 50 per cent. A whole lot of other similar unethical practices! So I think over the years this has gradually infiltrated the medical profession and made it very, very unhealthy indeed. Today the principle reason to become a doctor is to become rich, fast, very quickly, and the principle goals are a huge big flat, a Mercedes Benz car, travels abroad twice a year, thrice a year, on holiday, and so on and so forth.

Margaret Coffey: How did this happen I ask. How come, when India has so much in the way of resources to draw upon? Not just the Western style professional medical ethic inherited from the British connection, but rich sources within Hindu tradition, within the Vedic sources?

Dr Sunil Pandya: We had two great teachers somewhere around 2000 to 3000 years ago – the dates are disputed – one was a physician called Charak, and the other was a surgeon called Sushrut. Both of them have left behind their works - like the Corpus Hippocraticum, there is a corpus of writings under Charak's name and a corpus under Sushrut's name. We're not very sure whether they were actually written by them or some by them and some by their disciples. We have these two bodies of knowledge which have been passed down, and we have Sanskrit manuscripts and now of course we have English translations and all kinds of commentaries on them. Both of them have ethical codes enshrined in these works and those ethical codes are exemplary – you could take them and you could use them today and they are better than international code that I have seen so far, because they have codes for who should be a student of medicine, who should be a teacher of medicine, how should medicine be taught, what is expected of the graduate, and how will he behave under a variety of circumstances. So there were lots and lots of very interesting ethical principles which were passed on in these works, and we have forgotten all of that. It's gone!

Margaret Coffey: Sunil Pandya has written vigorously about the resources in the Vedic literature for contemporary thinking through issues in medical ethics, including medical training and practices. You can find a link to one of these essays on Encounter's website – just go to RN and locate the Encounter program. But I'm on my way now to meet a Sanskrit scholar, at an eminent postgraduate studies institute which is one of 34 in a conglomerate affiliated with the University of Mumbai. The conglomerate was set up by yet another donor who believed that Indian professional education had to be built on a foundation in morality and values inspired by the Indian ethos and culture. Like everything in Mumbai, it takes a bit of finding! The donor was particularly committed to Sanskrit studies and that's why I find –

Dr Kala Acharya: Kala Acharya –Acharya in Sanskrit means teacher and in our Vedic literature there are many references to acharya, the teacher and especially when the student completes his education then the teacher, preceptor, tells him before he leaves the hermitage of acharya, speak truth, do your duty and always give the discourse. It is not that knowledge is only for your sake, it is for everybody so you have to spread the knowledge… and that's why he says ..[language]

I've heard people lament the lack of attachment to India's great tradition in contemporary India – that you know people really are only thinking about money , wealth and the pursuit of personal satisfaction. Do you agree with that, that there's been an abandonment of India's great tradition and all its moral insights?

Kala Acharya: We cannot call it as an abandonment. It is true that nowadays people are after money. In the 8th century we had Shankaracharya ,the most prominent philosopher, and he is revered as the preceptor of the entire world - Jagadguru they call him. In one of his popular hymns he says [Sanskrit]. He said that somebody is handsome, but he is not happy, what next? He needs a beautiful wife .. Then again [Sanskrit] what next I want? He feels like that. Then he wants son, then the house, then what next…The success in one's own country and success or name in other country, he says. The highest riches, even if one get, one is not happy. So it is the tendency of man that he wants more and more – he is really greedy. But, we have to choose what we want – whether we want to run after all these material or we want a spiritual life. So there is a trend that people are after material things in India, as they are in the world - India is not an exception, even though we have a great tradition, and it is our duty, duty of Indians, to make the new generation aware of their heritage, which tells them that you can aspire for money – that even dharma, that is religion, or you say religious practices, or karma, that is aesthetic sense, the things which help us lead nice sexual life, they are rooted in money, artha, wealth, but that wealth has to be obtained through righteous means. So the hierarchy is first dharma, that is righteous way of life, and then artha, then wealth, then kama, sexual life, and then liberation, moksha. So the graded way has been chalked out by Indians. What happens [is] that people want to go to the second – they don't want to practise dharma – that is righteous way or righteous means. They think that the ends will justify the means. It is not like that.

It will take some time for us to bring back our new generation to the heritage but I am sure that it is very much in their blood, very much in their heart. It is actually we who are not capable of transmitting the message. We should be very firm about that in our mind – that we have to do that, when we know that our Isha Upanishad says [Sanskrit] Enjoy, but with sharing!

Margaret Coffey: Your account always returns to Indian philosophy and its riches. I wonder what you think of contemporary Hindu practice I suppose, and Hindu culture, it seems to be so very ritually taken up and not quite so much philosophically taken up, as it is in your life.

Dr Kala Acharya: Sometimes people bifurcate religion and philosophy – in other countries there is a division clear cut, whereas in Hinduism religion and philosophy always went hand in hand. It is true that people, in their mind what is religion? Religion means particular rituals – taking a bath, offering worship to God etc. There are also scriptures, which says that external purity is not purity. One beautiful example I give you, that in rituals we give a lot of importance to bath and especially bath in Ganga (Bathing in the Ganges). Then one poet says that if by taking bath in Ganges we become pure, then the fish in the Ganges must be the most pure creatures in this world because they are always in the water. So it is not the philosophy which is behind the rituals that has to be brought into practice so these two things going together is rare – but it is still found in India. I don't say it is absent. But what you are saying is correct – people mistake religion for ritualism.

Margaret Coffey: Kala Acharya in Mumbai, and you'll hear more from her in a future Encounter about inter-religious contacts in India – she's been a pioneer of interfaith conversations of a more than usually searching kind.

Check us out online – where you can find links and a transcript, as well as photos of some of the guests in this program.

Back at Saragur's hospital I'm being given a tour …

Music:Raga 'Lankadahang Sarang', Tr 4 from Indian Ragas and Medieval Song, Modal Melodies from East to West. DRS2

Dr Seetharam: This is the paediatrics outpatients. So we try to make sure that on specific days, specific opds are run. So by now patients are aware which doctor will be available on which day, so they come on those specific days. So every room will have an assistant like this. They are local boys and girls who have been trained in basic nursing - that is, more than nursing - interacting with the people – not patients, but people. So that they talk to the people as people not necessarily as some symptoms or signs and such stuff and try to make them comfortable and help them move around in the hospital. Many times patients will not know where to go and how to go and what to do and such stuff. They are also trained in some amount of nursing but they are focussed more on the nontechnical aspect as well.

This is Dr Kumar. He is our paediatrician. He is also the secretary of our organisation. He heads our research division and is leading the ethical review board as well. He sees patients on specific days. keeps some time reserved for the research activities and ethical review activities.

Margaret Coffey: I'm told that Dr Kumar not only chairs the hospital's ethical review board, he's also leading three research projects, each based on local culturally and environmentally specific health needs. One example: how to keep infants safely warm in their electricity free forest homes. As Dr Seetharam explains, the ethical review board is unusual.

Dr Seetharam: This is a very serious affair for us. Not many hospitals, not many institutions have an ERB of their own. Our hospital has been a trend setter and we are trying to broad base it to the best extent possible. So it has actually been an empowerment process for the local community also. A person, a woman from the Sargur town has served as a member of this board, a school teacher in the local community has been involved in certain of the discussions so it's actually enriching because we get a perspective that otherwise we would not be aware of.

Margaret Coffey: And I find out how the younger Dr Kumar came to work at the hospital and become part of the SVYM organisation.

Dr Kumar: It's very difficult to say. I was not sure what to do. I had come here as a medical intern actually. So when I came here I was really impressed by the way they were handling each patient and everything – I felt it was really touching my heart really. So I felt it was the best place to work and I should also join my hand with that kind of service.

Margaret Coffey: Thank you.

I realise I haven't yet asked a question about caste. And I'm also curious about how the spiritual not religious emphasis of SVYM integrates non-Hindus. How do the SVYM's values modify these social divisions? So in the car on the way back to Bangalore Dr Sridevi explains.

Dr Sridevi Seetharam: We have close to 600 people working for the organisation fulltime. When we interview staff religion is never a criteria for selection and even in the workplace religion is never a main issue that plays out in the work. Even in India religion is a very private thing – it is not usually discussed in the public arena. But on the other hand, when we look at a service in the true sense there is a universality to it – every religion recognises and values it. So each person is interpreting service as he understands it as from his personal perspective as well as from his religious perspective. And since there is no discrimination of any kind based on the religion of a person everybody feels free and as if they belong here. And we also value that as it has enriched our work environment and it has made our staff more understanding about each other and they understand that everybody comes from the same value system.

Margaret Coffey: You're integrating across different communal identities but also through classes, when you are employing you know local people and training them up?

Dr Sridevi Seetharam: Oh yes, definitely. In most job markets there is a space for writing your caste in the job application. Even in a NGO when people apply for a job they have to fill in this space because sometimes we need to tell the government what percentage of the staff come from the reserved classes, because the government is looking for equal opportunity from a different perspective. The information is not used for any other purpose. Once they are a member of an organisation or the staff of an organisation they are treated as everybody else.

Margaret Coffey: But on the other hand, having to fill in that, people's capacity to do that, they know their caste, it's still meaningful for them!

Dr Sridevi Seetharam: Most people are very aware of their caste. In urban areas it is not so very apparent but in rural areas caste is a very important determinant of social dynamics and interaction – with whom you can sit, with whom you can eat and drink, in to whose homes you have permission to enter, all this is determined by caste. Amongst the educated class, people who have travelled, known people from different backgrounds, it is not such a major factor. But otherwise in rural areas caste system still is very, very rampant. We have staff who are very conscious about their caste when they go back home, but when they are in the workplace we all sit together, eat together, travel together, so they feel comfortable. But the same people when they go back home, they follow a different social system.

Margaret Coffey: Dr Sridevi Seetharam, from the Swami Vivekananda Youth Movement in Saragur, south India. Coming up there are clearly plenty of areas for the Indian Journal of Medical Ethics to explore. Its editor, Amar Jesani, describes two challenges as far as the philosophical bases of medical ethics in India are concerned. The first challenge concerns what's called AYUSH, the government mandated traditional healing methodologies, including Ayurveda, that remain widely used, including in the SVYM hospital network.

Amar Jesani: How do we try to recapture the tradition because the traditional systems of healing are still prevalent and used a lot in healing. This is one major challenge, how to integrate them and how to promote some research on the ethical system of this traditional medicine and get that literature out in the journal so that the larger medical profession can learn from it.

The second challenge we are trying to address is by linking up more and more with philosophy departments. The Philosophy departments in [the] last two decades in India have tried to work more on the Indian philosophies. You will find in coming time, at least in the next two years, some of these philosophers writing regularly in the Indian Journal of Medical Ethics.

Margaret Coffey: So you do feel a responsibility towards integrating thinking about medical ethics with the dominant philosophical traditions in India?

Amar Jesani: Well there is going to be a lot of dialogue between the Indian philosophical tradition as well as the western philosophical tradition. I think it is not going to be a very jingoistic marriage; it is going to be more of a learning from all the traditions rather than being one-sided about it.

I have been studying all these aspects and my findings so far are very mixed because the Hindu philosophical practices have on the one side a very rich heritage. On the other side Hinduism itself has been riddled with a lot of differences and hierarchies. It is the only religion that I know in the world where a part of the followers are considered untouchable for centuries and they were kept out of even reading religious texts. So you know Hinduism has a strong good philosophical side on the one hand and at the same time it had certain practices. And for me ethics is nothing but you know practical philosophy – how you practice in your life. That is very, very important. We have to accept that the mainstream religion has this divisive force within.

Hinduism is not just one text system. It has a multiple traditions within it and so we will have to open up to all of them in order to see that the representation to a religion does not become representation to a dominant caste which is more articulate and learned as compared to the others. So the tasks are very complex in India.

Margaret Coffey: Amar Jesani, the editor of the Indian Journal of Medical Ethics.

My thanks to the people of the Swami Vivekananda Youth Movement hospital at Saragur, to Dr Kala Acharya, and to the past and present editors of the Indian Journal of Medical Ethics, Sunil Pandya and Amar Jesani. You can find more information about each of these people and their places of work at abc.net.au/rn... just locate Encounter. There's streaming audio and a podcast, and this time round a transcript, along with some other audio from Saragur, including a discussion of attitudes towards abortion, and an interview with the principal of the Saragur SVYM school. Thanks to Cary Dell for sound engineering. I'm Margaret Coffey.

Music:Raga 'Lankadahang Sarang', Tr 4 from Indian Ragas and Medieval Song, Modal Melodies from East to West. DRS2

Guests

Dr Kala Acharya

Dr Amar Jesani

Dr Seetharam

Dr Sridevi Seetharam

Dr Sunil Pandya

Publications

Title

Cross-Cultural Perspectives in Medical Ethics

Author

(Ed) Robert M. Veatch

Publisher

Jones and Bartlett Publishers, Sudbury, Massachusetts 2000

Description

Prakash N. Desai contributes to this book a survey of the building blocks from which an Indian medical ethics is derived and illuminates ways in which contemporary issues can be approached via these ancient resources.

Further Information

Dr Kala Acharya is Director of this postgraduate research centre for studies in Indian Culture, Philosophy, History, Sanskrit language and Yoga. The late Padmabhushan Shri Karamshi Somaiya was the founder of Somaiya Vidyavihar and also the donor of the land and resources for the institution. His son Dr. Shantilal Somaiya continued the family leadership of the Somaiya Vidyavihar through his contribution to interfaith dialogue and the legacy is carried out by the present vice president of Somaiya Vidyavihar, Mr.Samir Somaiya.